root cause analysis (rca) vs. shallow cause analysis …€¦ · root cause analysis (rca) ......
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Root Cause Analysis (RCA) vs.
Shallow Cause Analysis (SCA):
What’s the Difference?
Bob Latino, CEOReliability Center, Inc.www.Reliability.com
First Time Attendee
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Objectives
1. Viewing RCA as a system and not simply a task2. Pro’s and con’s of common tools to express logic3. Constructing a logic tree to tell a story4. Practical Case Studies: The nature of the failure is
irrelevant.
2
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Viewing RCA as a system
and not simply a task
1
Latent Roots
Org. System Deficiencies
Workplace Cultural Influencers
Sociotechnical Factors
Undesired Consequence
Failures
Physical Roots
Errors (Human Roots)
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RCA System Process Flow Diagram
4
Preserve
Order
Analyze
Communicate
Track
Retain Incident
Information
Determine RCA Is Required
Gather Additional Data
Select Team
Members
Establish Functional Guidelines
Review Available
Data
Develop and Verify Hypothesi
s
Determine Verification Data
Needs
Report Team
Findings
Present Team Recommendations
Implement Recommendations
Measure Effectiveness
“First-Pass” Data Collection
Build Logic Tree
Triggered RCAs - ReactiveChronic Failures - ProactiveHigh Risks - Proactive
Inputs
Develop and Verify Hypothesis
Build Logic Tree
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Pro’s and con’s of common tools to express logic
2
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Event
Mode Mode
Hypothesis
Physical
Human
Latent Latent
Hypothesis
5-WHY FISHBONE LOGIC TREE
Common Analysis Tools
6
Comparison
Problem
Why?
Why?
Why?
Why?
Why?
Cause
How Can?
How Can?
Why?
Materials
Man Mgmt
Machines
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Constructing a logic tree to tell a story -
Concept
3A
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Policies & Procedures
Human Performance/
Human Factors
Communication Systems
Technology Systems
Training Systems
Management Oversight/
Enforcement
Cultural Norms & System’s Failures (Defenses)
Undesirable Outcome
(least acceptable consequence)
Undesirable Outcome
(least acceptable consequence)
Physical Roots
Human Roots(Active)Latent Roots
How one labels causes/contributing
factors, doesn’t matter!
Germination of an Undesirable OutcomeThe Basics
Triggering Decision
Near Miss
Observable Consequences
H
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Anatomy of a Logic Tree
9
Going beyond the Blame Game
Latent Roots
Org. System DeficienciesWorkplace Cultural Influencers/
Just CultureSociotechnical Factors
Undesired Consequence (Event)
Failures Modes
Physical Roots
Errors (Decisions/”Choices”)
Root Cause Failure Analysis (RCFA)
Decision Error Analysis (DEA)
Layers of Human Performance
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The Hourglass ViewTransition from Deductive to Inductive Thinking
10
Undesirable Outcome(Physical Manifestations)
Human Root Causes(Behavior Related)
Latent Root Causes(Systems Related)
Deductive(General to Specific)
Physics (H
ard)
Inductive(Specific to General)
Hum
an (Soft)
RCFA
DEA
(How Can?)
(Why?)
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Constructing a logic tree to tell
a story -Application
3B
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Root Cause Analysis: The establishing of logically complete, evidence-based, tightly coupled chains of factors from the least acceptable consequences to the deepest significant underlying causes (www.rootcauselive.com)
Logic Trees are a Component of RCARCA Definition I Use…
(Bear with me, that’s a mouthful…)
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How Can?
How Can?
How Can?
Why?
logically complete
evidence-based
tightly coupledVerification Log (5P’s)
Verification Method –
Verification Outcome –
Responsibility –
Due Date -
HOW COULD? vs WHY?Categorical vs Cause-
and-Effect
In More Simplistic TermsLogic Tree Expression Used for ‘Reconstruction’
t
PR
HR
LR
EventMode(s)
H H
H H
E
M M M M
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Role Playing Give me a hand with the logic…
Event
Modes
Top Box - Facts
Do We Do RCA on Incidents?
What Would be the ‘Event’ if We Had a Critical Pump Failure?
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Unexpected Production Shutdown
Motor Failure
Critical Pump Bearing Failure
Seal Failure
Role Playing Give me a hand with the logic…
Event
Modes
Top Box - Facts
How Can?
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The Process Basics
16
From the Driver to the Driven
Pump (Driven)Motor (Driver)
Roller Bearing
Shaft
“How can a bearing fail?”
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Unexpected Shutdown
Motor Failure
Critical Pump Bearing Failure
Erosion Corrosion Fatigue Overload
Seal Failure
Role Playing
17
Give me a hand with the logic…
Event
Modes
Top Box - Facts
Then, Once Again…’How Can?’
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Quick Lesson in Component FailureMetallurgy 101
Source: http://www.reliability.com/failure-scene-investigation.html
Erosion
Uniform Loss of Metal
Corrosion
Pitting (Electrical
Phenomena)
Fatigue
Cyclic Failure
Overload
Instantaneous Fracture
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Delta MD88 Oil Cap Issue
19
Delta Reputational
Loss
Plane ‘Call Back’ Due to Smoke
MD88 APU Oil Cap Loose
LTA Cap Design –Appears Locked
Cap Seal Failure
LTA Tightening
Failure to Detect
Other Hypotheses
Event
Mode
How Can?
How Can?
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Exploratory vs. Explanatory Logic TreesStorytelling Tool
20
Such an expression demonstrates
relationships between systems, decisions and
outcomes…a Story!
= Exploratory
= Explanatory
E
M M MM
H
H
H
PR
HR
LR LR LR
LR LR
HR
PR
H
H
H
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Correlating Swiss Cheese to a Logic TreeReasons, James. Human Error. 1990.
Swiss Cheese Goals1. Minimize # of Holes2. Minimize Diameter of Remaining Holes3. Don’t Let Remaining Holes Line Up
Event
Mode 1
HYP 1
PR
HR
LR 1 LR 2 LR 3
HYP 2
Mode 2
Event
Latent
Human
Physical
Modes
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Prove that such practical tools can be
applied anywhere, by anyone…even a 5th grader!
4
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Practical Case #1: Industrial Case Study
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Let’s Put These Concepts into Practical Reality!
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Unexpected Shutdown of Production
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Source: Screenshots used with permission from www..reliability.com
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How Can?
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How Can?
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How Can?
How Can?
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How Can?
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Why?
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Why?
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Why?
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So What is the Difference Between RCA and SCA?...It Depends!
33
Latent Roots
Org. System Deficiencies
Workplace Cultural Influencers
Sociotechnical Factors
Undesired Consequence (Event)
Failures Modes
Physical Roots
Errors (Decisions)
SCA
RCA
Breadth
Depth
Evidence Strength
Effectiveness (ROI)
Knowledge MgmtStructure- AI, IIoT, ML, DL
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Thanks for Your Time!www.Reliability.com
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